Patient Intake

Please complete this form for each patient who needs Dr. Arce for BOTH surgical and sedation services. You only need to submit this once per patient — Dr. Arce reviews every request personally and sends a calendar invite.

Sedation fees — paid in full directly to In-Office Specialist LLC. No insurance billing, no percentage deductions: the fee listed is what Dr. Arce receives.

Oral sedation — $500
Moderate IV sedation — $2,000 (up to 4 hours)

Payment via Zelle: 281-760-9270

OfficeOffice name *Your email (office contact) *We'll use this for any follow-ups about this patient.

PatientPatient's full name *Patient's date of birth *Patient's phone number *Patient's email *

Surgical procedureWhat surgical procedure do you need Dr. Arce to perform? *

ProcedureSedation type *Who is responsible for the bill? *

Visit duration

Half day (4 hours)Full day (8 hours)

Preferred date *Dr. Arce will confirm a specific time on this date and send a calendar invite.

Preferred time *

Morning (AM)Afternoon (PM)Either

What happens after you submit: Dr. Arce reviews your request personally and sends a Google Calendar invite with the confirmed time, usually within one business day. The calendar invite is the confirmation — no second step on your end.

ClinicalPatient allergies *Preferred pharmacy *Medical history (PDF, up to 5 files, 50 MB each) *Files upload directly to Dr. Arce's secure Drive folder; no patient data passes through this site's server.